Punjab

Faridkot

CC/17/392

Harmandeep Singh - Complainant(s)

Versus

HDFC - Opp.Party(s)

Ashu Mittal

15 May 2019

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :             392 of 2017

 Date of Institution:  12.12.2017

Date of Decision :    15.05.2019

 

Harmandeep Singh aged 38 years, s/o Paramjit Singh, r/o # 67, Kirat Nagar, Faridkot, Tehsil and District Faridkot.

                                                                                        ...Complainant

Versus

 

1. HDFC Bank Branch Faridkot through its Manager.
2. HDFC Ergo General Insurance Company Ltd, 1^st Floor, 165-166, Backbay Reclamation, H T Parekh Marg, Churchgate, Mumbai-400020 through its M. D.

                                                                              .......Ops

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh  Ajit Aggarwal, President,

              Smt Param Pal Kaur, Member.

 

Present: Sh Ashu  Mittal, Ld Counsel for complainant,

              Sh Atul Gupta, Ld Counsel for OP-2,

              OP-1 Exparte.

 

ORDER

(Ajit Aggarwal, President)

                                          Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs

cc no.- 392 of 2017

seeking directions to OPs to make payment of insurance claim worth Rs. 2,35,000/-pertaining to mediclaim insurance policy bearing no.50205037 and for further directing OPs to pay Rs 50,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses.

2                                              Briefly stated, the case of the complainant is that on assurance of Ops that they would provide cashless treatment during the subsistence of policy, complainant purchased a mediclaim insurance policy bearing number 50205037and got renewed the same from time to time. It is submitted that present insurance policy is valid from 11.04.2016 to 10.04.2017 and as complainant did not make any claim earlier regarding previous policies and kept renewing the policy, therefore, OPs gave him cumulative bonus of Rs.60,000/-in addition to sum insured amount in renewed policy and thus, complainant is insured to the amount of Rs.2,60,000/-. Further submitted that in December, 2016 complainant felt heart pain and on advice of Dr Naveen Kumar, complainant got checked him up from Max Hospital, Bathinda, which is empanelled hospital of OPs. Doctors in Max Hospital, Bathinda, conducted some tests upon complainant and told that there is some blockage in his heart and he needs to implant stent in his heart. On recommendation of hospital authorities, complainant got ready to implant stent in his heart and then, hospital authorities intimated about this fact to OPs, who had not allowed hospital authorities to provide cashless treatment on false ground. Thereafter, operation was conducted and stent was placed in the heart of complainant. It is further submitted

cc no.- 392 of 2017

that before placing stent, complainant told hospital authorities that he has been suffering from Thyroid for about last ten months. After operation, hospital authorities told complainant that OPs have rejected the claim of complainant on the ground that he is suffering from Thyroid and now, complainant was to pay the bill for his operation. Complainant did not have money and thus, he took loan of Rs.2,40,000/- under Instant Jambo Loan and paid the entire bill to hospital  authorities.  After that complainant approached OPs several times and made many requests to make payment of his claim amount and tried to convince them that he is suffering from thyroid for the last ten months only and not for last ten years, but they did not pay any heed to listen to his requests and rejected the claim of complainant on this ground whereas there is no concern between Thyroid and IWMI, which amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to him. ld counsel for complainant submitted before the Forum that earlier complainant filed this complainant on 3.02.2017 but vide order dated 10.08.2017 it was disposed off by ld Forum being premature and complainant was directed to submit all requisite and relevant documents with OPs. Complainant submitted all the documents for processing his insurance claim to OPs, but this time again, they have not settled the claim of complainant on false grounds which amounts to deficiency in service and trade mal practice on the part of Ops. He has prayed for directions to Ops to pay the insurance claim and for further

 

cc no.- 392 of 2017

directing them to pay Rs.50,000/- as compensation besides cost of litigation. Hence, the present complaint.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 18.12.2017, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OP-2 filed reply taking preliminary objections that complaint is not maintainable in the present form as complainant has not come to the Forum with clean hands. Allegations levelled by complainant are false, frivolous and vexatious. Complainant wants to gain undue monitory benefits and no cause of action arises against OPs. Present complaint is premature as complainant never lodged his claim for reimbursement with them. Complainant neither submitted any claim form nor any documents in support thereof. He did not comply with the order dated 10.08.2017 passed by this Forum and did not submit any claim form or documents for processing his claim for reimbursement of expenses incurred by him. it is averred that a pre-authorization/cashless request was received from Max Super Speciality Hospital, on which Op-2 raised a query and in reply to that query, a certificate was issued by treating doctor of Max Hospital and on perusal of which it was found that complainant has been suffering from Hyperthyroidism much before the inception of policy in question and there was a history of last 10 years for this disease, which

cc no.- 392 of 2017

complainant did not disclose the answering Ops while purchasing the present policy and on account of non disclosure of material facts, cashless claim was denied under section 10 (r) (ii). It is further averred by OPs that denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed to complainant and this fact was duly intimated to complainant in cashless denial letter dated 26.12.2016 and after rejection of cashless claim, no other claim for reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. However, on merits, they have denied all the allegations of complainant being wrong and incorrect and reiterated the same pleadings as taken in preliminary objections. It is further averred that there is no deficiency in service on the part of OPs and all the other allegations levelled have been denied being wrong and incorrect and prayed that complaint deserves to be dismissed with costs.

5                               Notice containing copy of complaint alongwith relevant documents was served to OP-1, but despite having sufficient notice of complaint, OP-1 did not appear in the Forum either in person or through counsel to contest the case on date fixed and then, after long waiting till 4.00 O’ Clock, when no body appeared in the Forum on behalf of OP-1, it was proceeded against exparte vide order dated 6.02.2019.

cc no.- 392 of 2017

6                                               Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to C-7 and annexure C-8 and C-9 and then, closed his evidence.

7                                                  In order to rebut the evidence of the complainant, the opposite party-2 tendered in evidence, affidavit of Shweta Pokhriyal as Ex OP-1, documents Ex OP-2 to 6 and then closed the evidence on behalf of OPs.

8                                              We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

9                                                Ld Counsel for complainant vehementally argued that on assurance of Ops that they would provide cashless treatment during the subsistence of policy, complainant purchased a mediclaim insurance policy bearing number 50205037and got renewed the same from time to time. It is submitted that present insurance policy is valid from 11.04.2016 to 10.04.2017 and as complainant did not make any claim earlier regarding previous policies and kept renewing the policy, therefore, OPs gave him cumulative bonus of Rs.60,000/-in addition to sum insured amount in renewed policy. Further submitted that in December, 2016 complainant felt heart pain and on advice of Dr Naveen Kumar, complainant got checked him up from Max Hospital, Bathinda, which is empanelled hospital of OPs.

cc no.- 392 of 2017

Doctors in Max Hospital, Bathinda, conducted some tests upon complainant and told that there is some blockage in his heart and he needs to implant stent in his heart. On recommendation of hospital authorities, complainant got ready to implant stent in his heart and then, hospital authorities intimated about this fact to OPs, who had not allowed hospital authorities to provide cashless treatment on false ground. Thereafter, operation was conducted and stent was placed in the heart of complainant. It is further submitted that before placing stent, complainant told hospital authorities that he has been suffering from Thyroid for about last ten months. After operation, hospital authorities told complainant that OPs have rejected the claim of complainant on the ground that he is suffering from Thyroid and now, complainant was to pay the bill for his operation. Complainant did not have money and thus, he took loan of Rs.2,40,000/- under Instant Jambo Loan and paid the entire bill to hospital  authorities.  After that complainant approached OPs several times and made many requests to make payment of his claim amount and tried to convince them that he is suffering from thyroid for the last ten months only and not for last ten years, but they did not pay any heed to listen to his requests and rejected the claim of complainant on this ground whereas there is no concern between Thyroid and IWMI, which amounts to deficiency in service and has caused harassment and mental agony to him. He has prayed for accepting the complaint alongwith compensation and litigation expenses.

 

cc no.- 392 of 2017

10                                                  To controvert the allegations of complainant, ld counsel for OPs asserted that complaint is not maintainable in the present form as complainant has not come to the Forum with clean hands. Allegations levelled by complainant are false, frivolous and vexatious. Complainant wants to gain undue monitory benefits and no cause of action arises against OPs. It is admitted that complainant is insured under policy in question, but denied all the other allegations and stressed mainly on the point that complainant never lodged his claim with them. Complainant did not submit claim form and supporting documents to get his claim. It is averred that they raised query to hospital on receipt of preauthorization from hospital in reply to which they issued certificate and from the perusal of certificate issued by treating doctor of Max Hospital, it is observed that he has been suffering from Hyperthyroidism much before the inception of policy in question and there was a history of 10 years for this disease, which complainant did not disclose the answering Ops while purchasing the policy in question and on account of non disclosure of material facts, cashless claim was denied under section 10 (r) (ii). It is further averred by OPs that denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed to complainant and this fact was duly intimated to complainant in cashless denial letter dated 26.12.2016 and after rejection of cashless claim, no other claim for

cc no.- 392 of 2017

reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. It is further averred that there is no deficiency in service on the part of OPs and prayed for dismissal of complaint.

11                                                 From the careful perusal of record and after going through the affidavits, evidence and pleadings of the parties, it is observed that grievance of complainant is that he was insured under the policy of Ops for cashless treatment and during the validity of insurance period, he felt heart pain and on advice of Dr Naveen Kumar, he  got himself checked up from Max Hospital, Bathinda, where he  was recommended to place stent in his heart as there was blockage in his arteries and it was a risk to his life. Hospital authorities told about this fact to OPs, who had not allowed them to provide cash less treatment to complainant. Before operation, complainant disclosed treating doctor that he is suffering from thyroid for about last ten months. Complainant underwent surgery of stent implantation at Max Hospital, Bathinda which is empanelled with OPs, but Ops did not provide cashless treatment and rejected his claim on the ground that complainant is suffering from Thyroid. Efforts made by complainant to convince OPs that he is suffering from thyroid for only last ten months and not from ten years bore no fruit and they repudiated the claim of complainant. Under compelling circumstances, complainant had to take loan for making payment of expenses occurred on his treatment. All this amounts to deficiency in service. In reply, Ops

cc no.- 392 of 2017

admitted that complainant was insured with OPs and stressed mainly on the point that complainant did not lodge claim with them. He did not submit claim form and other documents with them. moreover, complainant concealed that he was suffering from thyroid for last ten years. Denial of cashless claim to complainant does not amount to final denial of entire claim and further claim for reimbursement of claim can be lodged after the treatment. On perusal of treatment documents, if the claim is found payable, it would be reimbursed and this fact was also intimated to complainant vide letter dated 26.12.2016, but after rejection of cashless claim, no other claim for reimbursement of expenses was ever lodged by complainant and thus, complaint filed by complainant is premature and it is liable to be dismissed. There is no deficiency in service on the part of OPs and prayed for dismissal of complaint.

12                                   To prove his pleadings, ld counsel for complainant placed on record copy of Policy Schedule which makes it clear that complainant was insured under policy in question and he had paid premiums with Ops. Ex C-3 is copy of letter issued by Ops to complainant vide which they showed their inability to redress his grievance. From document Ex C-7, which is copy of e-mail sent by Ops to complainant, it is clear that complainant submitted all the requisite documents with Ops. Bare perusal of this correspondence letter shows that documents submitted by complainant to them have been forwarded by them to their Claim Department. ExC-5 is copy of Track Consignment Detail that proves that complainant submitted all the

cc no.- 392 of 2017

documents pertaining to his genuine claim to OPs through Post Office. It contains tracking detail of documents sent by complainant to Ops from 3.10.2017 to 7.10.2017 from Bathinda to Noida. ExC-6 is copy of postal receipt that further proves the fact that complainant duly submitted requisite documents with OPs.

13                                            We have carefully gone through the file and from careful perusal of record, we come to the conclusion that there is no dispute about the insurance claim as it is admitted fact of Ops that complainant was insured with them. Plea taken by OP-2 that complainant did not submit claim relating documents to them has no legs to stand upon in the light of document Ex C-5 which is copy of track consignment and document Ex C-7 further proves the pleadings of complainant. ExC-7 is self explanatory as on this document Ops have themselves specified that they have forwarded the details of claim received from complainant to their Claim Department for processing.  There is not an iota of doubt that complainant submitted requisite documents for getting passed his claim to Ops.  Action of OPs in not passing the genuine claim of complainant amounts to deficiency in service and trade mal practice. Complainant has produced sufficient and cogent evidence to prove his grievance and all the documents placed on record by complainant are authentic and are beyond any doubt.

14                                              From the above discussion, pleadings and evidence produced by respective parties, this Forum is of considered

cc no.- 392 of 2017

opinion that there is deficiency in service on the part of OPs in not passing the claim of complainant. By mere saying that complainant has not lodged claim with them, Ops cannot escape their liability of making payment of genuine claim of complainant. Complainant has succeeded in proving his case and therefore, complaint in hand is hereby allowed. Ops are directed to make payment of Rs.2,35,000/-to OPs alongwith interest at the rate of 9% per anum from the date of filing the present complaint till final realization. OPs are further directed to pay Rs.5000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and for litigation expenses. Compliance of this order be made within 30 days of receipt of copy of this order, failing which complainant shall be entitled to proceed under section 25 and 27 of the Consumer Protection Act. Copy of order be given to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 15.05.2019                 

 

(Param Pal Kaur)                     (Ajit Aggarwal)

 Member                                     President